Pericardial Decompression Syndrome: A Case Series and Literature Review.

Cardiac tamponade is a medical emergency requiring prompt recognition and intervention to avoid potentially fatal consequences. We present a case series of ventricular dysfunction and cardiogenic shock following pericardiocentesis in 3 patients with pericardial effusions at The Ottawa Hospital between 2014 and 2020. This report highlights the need for monitoring post-pericardiocentesis and raises awareness of this phenomenon, particularly in patients with malignancy. We propose a novel pressure-monitoring protocol to guide drainage and prevent development of pericardial decompression syndrome. The novel teaching points include limiting drainage to prevent development of pericardial decompression syndrome and a protocol for intra-pericardial pressure monitoring.

La tamponnade cardiaque est une urgence médicale qui, à défaut d'une reconnaissance et d'une intervention rapides, peut avoir des conséquences potentiellement fatales. Nous présentons une série de cas sur des dysfonctions ventriculaires et des chocs cardiogéniques survenus après une péricardiocentèse chez trois patients présentant des épanchements péricardiques traités à l'Hôpital d'Ottawa entre 2014 et 2020. Notre article souligne la nécessité de surveiller les patients au cours de la période suivant la péricardiocentèse et met en lumière le phénomène de la tamponnade cardiaque, en particulier chez les patients atteints de cancer. Nous proposons un nouveau protocole de surveillance des pressions conçu pour guider le drainage et prévenir le syndrome de décompression péricardique. Les nouveautés à enseigner comprennent la limitation du drainage afin de prévenir le syndrome de décompression péricardique et un protocole de surveillance des pressions intrapéricardiques.

Multidisciplinary Code Shock Team in Cardiogenic Shock: A Canadian Centre Experience.

BACKGROUND: Cardiogenic shock (CS) is associated with high mortality. We report on a "Shock Team" approach of combined interdisciplinary expertise for decision making, expedited assessment, and treatment. METHODS: We reviewed 100 patients admitted in CS over 52 months. Patients managed under a Code Shock Team protocol (n = 64, treatment) from 2016 to 2019 were compared with standard care (n = 36, control) from 2015 to 2016. The cohort was predominantly male (78% treatment, 67% control) with a median age of 55 years (interquartile range [IQR], 43-64) for treatment vs 64 years (IQR, 48-69) for control (P = 0.01). New heart failure was more common in the treatment group: 61% vs 36%, P = 0.02. Acute myocardial infarction comprised 13% of patients in CS. There were no significant differences between treatment and control in markers of clinical acuity, including median left ventricular ejection fraction (18% vs 20%), prevalence of moderate-severe right ventricular dysfunction (64% vs 56%), median peak serum lactate (5.3 vs 4.7 mmol/L), acute kidney injury (70% vs 75%), or acute liver injury (50% vs 31%). Inotropes, dialysis, and invasive ventilation were required in 92%, 33%, and 66% of patients, respectively. Temporary mechanical circulatory support was used in 45% of treatment and 28% of control patients (P = 0.08). There were no significant differences in median hospital length of stay (17.5 days), 30-day survival (71%), or survival to hospital discharge (66%). Over 240 days (IQR, 14,847) of median follow-up, survival was 67% for treatment vs 42% for control (hazard ratio, 0.53; 95% confidence interval, 0.28-0.99; P = 0.03). CONCLUSION: A multidisciplinary Code Shock Team approach for CS is feasible and may be associated with improved long-term survival.

CONTEXTE: Le choc cardiogénique (CC) est associé à une mortalité élevée. Nous décrivons une approche où la prise de décision, l'évaluation rapide des cas et le traitement sont confiés à une « équipe de choc ¼ interdisciplinaire. MÉTHODOLOGIE: Nous avons examiné les cas de 100 patients hospitalisés en raison d'un CC sur une période de 52 mois. Les patients pris en charge par une équipe interdisciplinaire selon un protocole d'intervention déclenché par un code-choc (n = 64, groupe traité) de 2016 à 2019 ont été comparés à des patients ayant reçu des soins courants (n = 36, groupe témoin) de 2015 à 2016. Les patients de la cohorte étaient majoritairement de sexe masculin (78 % dans le groupe traité, 67 % dans le groupe témoin) et l'âge médian était de 55 ans (intervalle interquartile [IIQ] : 43-64) au sein du groupe traité par rapport à 64 ans (IIQ : 48-69) au sein du groupe témoin (p = 0,01). Les nouveaux cas d'insuffisance cardiaque étaient plus fréquents dans le groupe traité : 61 % vs 36 % (p = 0,02). Les patients hospitalisés en raison d'un CC avaient subi un infarctus aigu du myocarde dans 13 % des cas. Aucune différence significative n'a été relevée entre le groupe traité et le groupe témoin au chapitre des marqueurs d'acuité clinique, y compris la fraction médiane d'éjection ventriculaire gauche (18 % vs 20 %), la prévalence d'une dysfonction modérée ou sévère du ventricule droit (64 % vs 56 %), la concentration maximale médiane de lactate sérique (5,3 vs 4,7 mmol/l), l'insuffisance rénale aiguë (70 % vs 75 %) ou l'insuffisance hépatique aiguë (50 % vs 31 %). L'administration d'inotropes, la dialyse et la ventilation effractive ont été nécessaires chez 92 %, 33 % et 66 % des patients, respectivement. Une assistance circulatoire mécanique temporaire a été utilisée chez 45 % des patients du groupe traité et 28 % des patients du groupe témoin (p = 0,08). Aucune différence significative n'a été notée en ce qui concerne la durée médiane des hospitalisations (17,5 jours), la survie à 30 jours (71 %) ou la survie à la sortie de l'hôpital (66 %). Au cours d'une période de suivi médiane de 240 jours (IIQ : 14 847), le taux de survie était de 67 % dans le groupe traité vs 42 % dans le groupe témoin (rapport des risques instantanés : 0,53; intervalle de confiance à 95 % : 0,28-0,99; p = 0,03). CONCLUSION: Dans les cas de CC, l'intervention d'une équipe interdisciplinaire déclenchée par un code-choc est réalisable et pourrait être associée à une amélioration de la survie à long terme.

Transparency in Nigeria's public pharmaceutical sector: perceptions from policy makers.

BACKGROUND: Pharmaceuticals are an integral component of health care systems worldwide, thus, regulatory weaknesses in governance of the pharmaceutical system negatively impact health outcomes especially in developing countries 1. Nigeria is one of a number of countries whose pharmaceutical system has been impacted by corruption and has struggled to curtail the production and trafficking of substandard drugs. In 2001, the National Agency for Food and Drug Administration and Control (NAFDAC) underwent an organizational restructuring resulting in reforms to reduce counterfeit drugs and better regulate pharmaceuticals 2. Despite these changes, there is still room for improvement. This study assessed the perceived level of transparency and potential vulnerability to corruption that exists in four essential areas of Nigeria's pharmaceutical sector: registration, procurement, inspection (divided into inspection of ports and of establishments), and distribution. METHODS: Standardized questionnaires were adapted from the World Health Organization assessment tool and used in semi-structured interviews with key stakeholders in the public and private pharmaceutical system. The responses to the questions were tallied and converted to scores on a numerical scale where lower scores suggested greater vulnerability to corruption and higher scores suggested lower vulnerability. RESULTS: The overall score for Nigeria's pharmaceutical system was 7.4 out of 10, indicating a system that is marginally vulnerable to corruption. The weakest links were the areas of drug registration and inspection of ports. Analysis of the qualitative results revealed that the perceived level of corruption did not always match the qualitative evidence. CONCLUSION: Despite the many reported reforms instituted by NAFDAC, the study findings suggest that facets of the pharmaceutical system in Nigeria remain fairly vulnerable to corruption. The most glaring deficiency seems to be the absence of conflict of interest guidelines which, if present and consistently administered, limit the promulgation of corrupt practices. Other major contributing factors are the inconsistency in documentation of procedures, lack of public availability of such documentation, and inadequacies in monitoring and evaluation. What is most critical from this study is the identification of areas that still remain permeable to corruption and, perhaps, where more appropriate checks and balances are needed from the Nigerian government and the international community.

Optimizing Risk Stratification and Noninvasive Diagnosis of Ischemic Heart Disease in Women.

Ischemic heart disease (IHD) is an important and previously underappreciated cause of significant morbidity and mortality in women. Key differences exist in the pathophysiology, sex-specific risk factors, and clinical presentation in women compared with men, which influence diagnostic accuracy and utility of pretest risk assessments and noninvasive testing. Women are disproportionately affected by ischemia from microvascular dysfunction as evidenced by having less obstructive coronary artery disease on angiography, contributing to the challenge in diagnosis and prognosis of IHD in women via conventional methods, which tend to emphasize detection of epicardial stenoses. In this article, we review the utility, evidence for, and challenges of currently available risk assessments and noninvasive cardiac diagnostic tests in women. We propose an approach to investigation of the symptomatic woman with suspected IHD and selection of the appropriate testing modality. Finally, we explore opportunities for future research and highlight the urgent need for updated, evidence-based, Canadian guidelines specific to women with IHD.

Diffuse Subepicardial Late Gadolinium Enhancement After Heart Transplant: A Potentially Ominous Finding.

Late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging has prognostic utility in populations with cardiac disease, including heart transplant (HT) recipients. The etiology of specific LGE patterns and their correlation with outcomes after HT are unclear. Antibody-mediated rejection and cardiac allograft vasculopathy are major causes of death, and their evaluation remains challenging. We report identical diffuse subepicardial LGE in 2 highly allosensitized HT recipients who developed allograft failure. We postulate this LGE pattern may be related to antibody-mediated rejection and cardiac allograft vasculopathy, and portends poor outcomes. These cases illustrate a potential role of cardiac magnetic resonance for antibody-mediated rejection evaluation and risk stratification.